Get Sample Request Fax Form -

This guide provides clear instructions on completing the SAMPLE REQUEST FAX FORM online to ensure you receive your complimentary samples efficiently. By following these steps, users can navigate the process with confidence.

Follow the steps to complete your request form online.

1. Press the ‘Get Form’ button to access the SAMPLE REQUEST FAX FORM and open it in your preferred editor.
2. Begin by entering your practitioner information. Fill in your name, selecting your professional designation (MD, DO, PA, NP) by circling the appropriate option. This identifies your qualifications.
3. Provide your contact information. Enter your phone number, fax number, and email address (ensure no PO boxes are included). This data is essential for processing your request.
4. Specify your office address. Include the city, state, and zip code where you operate, as samples can only be delivered to the address listed on your DEA license.
5. Select the product request option by checking one of the boxes next to the descriptions of the ® products. Make sure to validate your selection against your needs.
6. Proceed to certify your request. Sign the form, add the date, and input your state license number, DEA license number, and their expiration dates. This confirms your eligibility and compliance with relevant laws.
7. If you wish to receive information about new products and services from Actavis, check the consent box. Otherwise, leave it unchecked.
8. After thoroughly reviewing the form for accuracy, you can save your changes. Depending on your needs, download, print, or share the completed form as required.

Complete the SAMPLE REQUEST FAX FORM online today to ensure timely receipt of your samples.